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" ..--ePtICAT10111 1011 VVEWPUMP PERMIT <br /> SAN JOAQUTA COUNTY PUBLIC HEALTH SERYtCES ~ <br /> E!!1.170N!f:EAiTAL HEALTH OIY:SiUN <br /> 4r <br /> P 0 BOX 388, 4415 14.SAM JOAGUIM ST, STOCKTON, CA 95201.389 <br /> t� <br /> i205!3G&3425 � <br /> ifON�iFiSN_-DA¢�PER�IF fkpfRf4 1 Y AR IflDtt iIA�ISF'JL.O ' <br /> (Caasp)ata la lt�iiealal �. <br /> Application is here by made to the Son Joaquin County for a p-rmit to Construct arwfjor intitnll <br /> meds In Compliance with Sen Joaquin County Develothe cork described. this application is <br /> ezx,t Title, Chapter 9.1115.] end the Stnr4ards of San Joaquin Lou+ty Public Health t•` <br /> Services, Environmentat Hct,lth Division <br /> { i <br /> Job Address/or A{P�NN � -- ! 1`yJ f y, ()�;;.tY - Parcel Sixe/APNM }-� <br /> r^ Owner's Hage�f i( s"C' 1 'X11 C (. Adlress�1lV.��! ! n U, > []� 1 ']!'h•/ <br /> � ���._� • Phnne N LC]t r�l iJ/ <br /> Lorl[I'aCtpr -c�-Addre65!!4� �}-���L 77�� <br /> Phone k•rJ��IJ 1 <br /> Sub contractor,•` Atldr ass <br /> Phone N <br /> 11PE OF WfW, [PVI IJ NEW.WELL i) REPLACEMENT WILL S7 M0NI1ORING WELL *_ () OTHER <br /> II DESTRUCTJON 11 OUT^Of-SERVSCE WELL LJ CEOPHrSICAL WELL N [I SOIL BORING <br /> (TNSTALLATION 11 WLL SYSTEM REPAIR CROSS•CCWNELT FPAIB <br /> [] VAPOR ErI RACT(0I1 WILL <br /> N <br /> YPE� I1 S <br /> I) I:ew Repair H.P. _ DEPTH PUMP SET�,GLFT. FIRST WAIER LEVEL16,5 <br /> ) QED USE CQNSIRUCTI� SC�i��TlDi S <br /> II INDUSTRIAL II OPEN BOTTOM DIA. OF WELL E%CAVA71ON J:A. OF CONDUCIOR CASING_ <br /> "STIC/PRIVATE (I GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC D!A,POL CASING() PUBLIC/WMICIPAL E) DRIVEN DEPTH OF GRVJT SEAL SPEC0 IRRIGATION/AG [7 OTHER PL111- <br /> GROUt SEAL INSTALLED BYGROL� EO HN)TORING CROi1T SEAL. PLIIPED: [] Yea [J No CONCRES1A Y 111;11 11 No <br /> f APPUX.OEPTN LOCKJILG CHESTER eM/STOVE PIPE <br /> PROPOSED CONZTRUCTLONIDMI-LING METHOD: MUD ROTARI AIR ROTARY AUGER CABLE OrNER � <br /> i 1 hereby certify that I have prepared this eppllcs4ion andthatthe work will be done in eccorcitnct with Sen Joaquin Courtly Ordinances, <br /> State Lave, and Rules and Regulation* of the San Joaquin County, Naar ower or licensed aoent's signature cJrtiffes the following.. "I <br /> cartify that in the performance of the work for which this permPr is issued, I Shall. not eap(oy persons subject to 602xKAN'S c(*pENSATION <br /> Laws of California." Contractor's hiring or sub-contreCting signature certifies the folLowfng: a I certify that in the performance ( <br /> of the work for which this permit is Issued., I shall employ persons subject to WORKMAN'S COMPENSATION Leu& of Catifornin. TNEAPPLICANT ' <br /> MUSF CAII 24)11011112 LN ADVANCE rOR LL REOOIAEO JNSPECTIONA AT(LOS]468.3423. Cumw(!tt drawinj at lower area P ovided. iW <br /> fTDst09 <br /> PLO1'~PLAN (Draw to Scale) Scale _'� to <br /> i. Wastes of atreets or roads nearest to or bounding the property. 4 Location of house sewage disposal ayotem or <br /> 2. Outtilte of the property, giving dimensions and North dl rection. propoved eypans ion of sewage dirposal syttema. <br /> 3. Diamisioned outlines and location of all existing aux! proposed S. Location of wells within rediux of IiO ft. on <br /> structures, including covered areas such as patios, driveway&, the property or ndjoining property. <br /> and walks. <br /> 1 <br /> , i <br /> i <br /> t <br /> 7F- <br /> i'i - . <br /> I Jill <br /> G" <br /> i E- ± <br /> DS:PARTMEKT USE ONLYD61/y �. t <br /> Application Accepted 2y�� �/`� mete � Area <br /> GrW% inspection By,_„_ - � Date PLrtp Inspection By <br /> bite <br /> Destruction Inspection 8y Date Comments:_ r� <br /> ACCOUNTING ONLY:' A04 FACN J <br /> PE COOED FEE INTO ANIOUNT REMITTED CHF CASH RECEIVED BY CCA11TErr #ERMITJSERV)CE REDDEST NUMON1 INVOICE - <br /> t eft I 141-116) <br />